Early United States experience with donation after circulatory death for heart retransplantation.

BACKGROUND

Donation after circulatory death (DCD) expands the heart donor pool, but outcomes after adult heart retransplantation (re-TX) are not well defined.

METHODS

Using UNOS STAR data (January 1, 2019 to October 1, 2025), we studied adults undergoing orthotopic re-TX. Exposure was donor mechanism (DCD vs donation after brain death [DBD]). The primary outcome was 365-day mortality assessed with Kaplan-Meier methods and multivariable Cox regression. We also performed 2:1 propensity-score matching (PSM) using prespecified covariates.

RESULTS

Among 474 re-TX recipients, 53 (11.2%) received DCD hearts; DCD use rose to 32% of re-TX in 2025 (partial year). Compared with DBD, DCD recipients had lower transplant acuity (ECMO 1.9% vs 18.3%; mechanical ventilation 0.0% vs 10.0%) and differed in allocation status (p<0.001), with more Adult Status 4 listings (56.6% vs 26.6%). Perioperative complications and early mortality were similar by donor type. Unadjusted survival did not differ at 90 days (log-rank p=0.51) or 365 days (p=0.42). In adjusted Cox regression, donor mechanism was associated with 365-day mortality (DCD vs DBD hazard ratio 2.27, 95% CI 1.02-5.02; p=0.044). In the matched cohort (DCD n=51; DBD n=96), survival differed by donor mechanism at 90 days (p=0.03) and 365 days (p=0.009).

CONCLUSIONS

DCD re-TX use is increasing and is concentrated in lower-acuity recipients. While perioperative outcomes were similar, risk-adjusted and matched analyses identified differences in 1-year survival by donor mechanism, supporting cautious, selection-sensitive implementation and continued evaluation as experience and follow-up accrue.